Blood Cancers and Bleeding Disorders

Medicine — Blood Cancers and Bleeding Disorders, NMC MBBS licence examination syllabus (Nepal Medical Council).

Blood cancers and bleeding disorders

Two patterns to recognise: the marrow that has stopped working, and the bleeding that tells you which part of clotting has failed.

Haematology intimidates students because the classifications are elaborate and constantly revised. At the level of a licensing examination and of a first job, almost none of that matters. What matters is recognising a small number of patterns and knowing which of them cannot wait until morning.

The first pattern is marrow failure: whatever is filling or destroying the bone marrow, the consequences follow the three cell lines — anaemia, infection, bleeding. When more than one line is affected, the marrow itself is the problem. The second is the pattern of bleeding, which distinguishes a platelet problem from a coagulation factor problem at the bedside, before any test is back.

🩺 Where this lives: Fever in a patient on chemotherapy is an emergency, and the reason it is missed is that these patients look deceptively well. With no neutrophils there is no inflammatory response — so there may be no pus, no localising signs, and a chest that sounds clear over a pneumonia. The fever may be the only abnormality. Antibiotics are given immediately, before the blood count returns and before a source is found, because deterioration from apparently well to septic shock is measured in hours.

💡 A note on numbers. This chapter gives no doses, no chemotherapy regimens, no cell count thresholds and no coagulation reference ranges — neutropenia definitions and transfusion triggers differ between guidelines, and chemotherapy is specialist. It also gives no leukaemia or lymphoma classification systems, since subtype nomenclature has been revised repeatedly and what is examinable here is recognition and emergency management. Anaemia is covered in its own chapter, transfusion in the Fluids chapter, and anticoagulants in the Cardiovascular Drugs chapter.

Marrow failure

The single most useful reflex is this: anaemia alone has a hundred causes, but anaemia together with a low platelet count and a low white cell count points to the marrow. That combination — pancytopenia — narrows the differential sharply to marrow infiltration, marrow failure, or destruction, and it changes the next step from an iron study to a blood film and a marrow examination. Ask explicitly for the film to be examined; the report frequently names the diagnosis.

Recognising blood cancer

WHAT SHOULD RAISE THE QUESTION THE SYMPTOM COMBINATION Unexplained bruising or bleeding, recurrent or unusually severe infection, and fatigue — occurring together, in someone with no obvious explanation. B SYMPTOMS — the systemic features Fever without infection DRENCHING NIGHT SWEATS — the sort that require changing bedding, not simply feeling warm Unexplained WEIGHT LOSS ON EXAMINATION LYMPHADENOPATHY — note the character: a reactive node is soft, tender, mobile and settles. A node that is HARD, FIXED, PAINLESS and PERSISTENT needs investigation, not a second course of antibiotics. SPLENOMEGALY and hepatomegaly Bone tenderness, particularly over the sternum Pallor, bruising, gum hypertrophy, mouth ulceration A CRITICAL LOCAL POINT: in this region TUBERCULOSIS is a leading cause of persistent lymphadenopathy, and HIV must be considered in unexplained lymphadenopathy or unusual infection. Both are in their own chapters. Lymphoma, TB and HIV can present very similarly, and all three require tissue or specific testing rather than assumption. IN CHILDREN, unexplained bruising, bone pain, refusal to walk, pallor and lymphadenopathy should raise the question of acute leukaemia — and bruising in a child also raises safeguarding questions, which are covered in the Child Mental Health chapter. Both may need considering at once.

The emergencies

💡 Exam angle: neutropenic sepsis is examined because the correct answer is counterintuitive — antibiotics are given before the neutrophil count is known and before a source is identified. A question stem describing a febrile patient a week after chemotherapy, with a normal-sounding examination, is testing whether you will wait for results. You do not. Note also tumour lysis syndrome, which occurs after treatment begins and produces hyperkalaemia, hyperphosphataemia, hyperuricaemia and hypocalcaemia — anticipated and prevented rather than treated.

Reading the pattern of bleeding

This distinction can be made before any test returns. Platelet problems bleed superficially and immediately — petechiae, purpura, bleeding gums, nosebleeds, heavy periods, and bleeding that starts the moment the skin is broken. Coagulation factor problems bleed deeply and with delay — bleeding into joints and muscles, large deep bruises, and bleeding that stops initially then restarts hours later. Haemarthrosis in particular is close to diagnostic of a factor deficiency.

THE PRACTICAL BLEEDING HISTORY ASK ABOUT PATTERN, not just presence: Where does the bleeding occur — skin and mucosa, or joints and muscles? Does it start immediately or after a delay? Has it happened after previous surgery, dental extraction, or childbirth? Is there a FAMILY history, and in which relatives? ALWAYS ASK ABOUT DRUGS. Warfarin, antiplatelets and NSAIDs account for a great deal of clinically significant bleeding, and patients do not always regard aspirin or over-the-counter painkillers as medication — a point made in the GI bleeding chapter and worth repeating here. ACQUIRED CAUSES ARE COMMONER THAN INHERITED ONES LIVER DISEASE — reduced factor synthesis plus low platelets from splenomegaly VITAMIN K deficiency — malnutrition, malabsorption, prolonged antibiotics, newborns without prophylaxis (see the Newborn chapter) DRUGS Immune thrombocytopenia DISSEMINATED INTRAVASCULAR COAGULATION INHERITED DISORDERS present earlier and with a family history: haemophilias with deep bleeding in males, and von Willebrand disease commonly with mucosal bleeding and heavy menstrual loss.

Disseminated intravascular coagulation

💡 Exam angle: the examinable point about DIC is that it is always secondary. Clotting factors and platelets are consumed faster than they are produced, so the patient bleeds and clots simultaneously — but the treatment is not primarily to replace what is missing. It is to treat the underlying cause: sepsis, an obstetric emergency, major trauma or malignancy. Blood product support follows local protocol alongside that, but DIC does not settle until the trigger is controlled.

Clinical reasoning: four presentations

🔍 Case 1 — fever a week after chemotherapy

PresentationA man receiving chemotherapy develops a fever. He looks reasonably well, his chest is clear and no source is apparent. The plan is to await the blood count and blood cultures before starting antibiotics.

ErrorWaiting.

ReasoningThis is neutropenic sepsis until proven otherwise. Without neutrophils there is no inflammatory response, so there may be no pus, no localising signs and a clear-sounding chest over a pneumonia. Looking well is characteristic of the early phase.

AnswerTake cultures and give broad-spectrum antibiotics immediately per local protocol, without waiting for the count or a source. Resuscitate as needed and escalate early.

🔍 Case 2 — three abnormal lines

PresentationA woman with fatigue is found to be anaemic. Her platelet count and white cell count are also low. She is started on iron and asked to return in three months.

Missed patternPancytopenia.

ReasoningAnaemia alone has many causes, but anaemia with low platelets and low white cells points to the marrow — infiltration, failure or destruction. Iron does not address any of them, and three months is a long delay.

AnswerExamine for lymphadenopathy, splenomegaly and bruising, request a blood film specifically, and refer for further investigation including marrow examination. Ask about B symptoms.

🔍 Case 3 — bleeding into a knee

PresentationA young man has recurrent painful swollen knees after minor injury, and bleeding that stops then restarts hours after dental work. His maternal uncle had similar problems. Platelets are normal.

PatternDeep, delayed bleeding with a family history.

ReasoningHaemarthrosis and delayed prolonged bleeding indicate a coagulation factor problem rather than a platelet one, and the pattern of affected male relatives on the maternal side fits an inherited factor deficiency.

AnswerCoagulation studies and specialist haematology referral. Avoid intramuscular injections and NSAIDs, and plan ahead for any surgery or dental procedure.

🔍 Case 4 — bleeding from everywhere

PresentationA woman with severe sepsis begins oozing from every cannula site and from her gums. Platelets are falling and clotting times are prolonged. Blood products are given repeatedly, but the bleeding continues.

DiagnosisDisseminated intravascular coagulation.

ReasoningDIC is always secondary — here to sepsis. Factors and platelets are being consumed faster than they can be replaced, so product support alone cannot keep pace while the trigger continues.

AnswerTreat the sepsis aggressively — source control, antibiotics, resuscitation — with blood product support per protocol alongside. DIC settles only when the cause is controlled.

Commonly confused

Confusion	The distinction	Why it matters
Anaemia alone vs pancytopenia	More than one line means marrow	Changes the investigation entirely.
Looking well vs not septic	No neutrophils, no inflammatory signs	Neutropenic sepsis looks deceptively mild.
Awaiting counts vs treating	Antibiotics before the count is known	Deterioration is measured in hours.
Reactive vs pathological node	Hard, fixed, painless, persistent	Not another course of antibiotics.
Lymphoma vs TB vs HIV	All cause lymphadenopathy here	Tissue or testing, not assumption.
Platelet vs factor bleeding	Petechiae versus haemarthrosis	Distinguishable before any test.
Immediate vs delayed bleeding	Platelets bleed at once; factors later	A history question that localises the defect.
Treating DIC vs its cause	DIC is always secondary	Products cannot outpace consumption.

Rapid revision

MUST-KNOW FACTS 1. Marrow failure affects three lines: RED, WHITE, PLATELETS. 2. Red → ANAEMIA · White → INFECTION · Platelets → BLEEDING. 3. Anaemia ALONE has many causes. 4. Anaemia WITH low platelets and low white cells points to the MARROW. 5. Ask specifically for a BLOOD FILM — the report often names the diagnosis. 6. Suspect blood cancer: bruising, infection and fatigue TOGETHER. 7. B SYMPTOMS: fever, DRENCHING NIGHT SWEATS, weight loss. 8. Examine for LYMPHADENOPATHY, splenomegaly, hepatomegaly, bone tenderness. 9. HARD, FIXED, PAINLESS, PERSISTENT nodes need investigation. 10. In this region TUBERCULOSIS also causes persistent lymphadenopathy. 11. Consider HIV in unexplained lymphadenopathy or unusual infection. 12. In children: bruising, bone pain, refusal to walk, pallor — think leukaemia. 13. Bruising in a child also raises SAFEGUARDING questions. 14. NEUTROPENIC SEPSIS: fever on chemotherapy = ANTIBIOTICS IMMEDIATELY. 15. Give them BEFORE the count is known and before a source is found. 16. There may be NO pus and NO localising signs. 17. The patient may look deceptively well early on. 18. TUMOUR LYSIS: high potassium, phosphate and urate, low calcium. 19. It follows the START of treatment — anticipate and prevent. 20. Also: hyperviscosity, CORD COMPRESSION, severe hypercalcaemia. 21. Cord compression: back pain with leg weakness or retention. 22. PLATELET bleeding is SUPERFICIAL and IMMEDIATE. 23. Petechiae, purpura, gums, nose, menorrhagia. 24. FACTOR bleeding is DEEP and DELAYED. 25. HAEMARTHROSIS and muscle haematoma. 26. PETECHIAE = PLATELETS · HAEMARTHROSIS = FACTORS. 27. Ask about previous surgery, dental work, childbirth and FAMILY history. 28. ALWAYS ask about drugs — warfarin, antiplatelets, NSAIDs. 29. ACQUIRED causes are commoner than inherited ones. 30. Liver disease, VITAMIN K deficiency, drugs, immune thrombocytopenia, DIC. 31. DIC is ALWAYS SECONDARY — sepsis, obstetric, trauma, malignancy. 32. In DIC the patient clots AND bleeds simultaneously. 33. TREAT THE CAUSE — DIC does not settle until the trigger is controlled. 34. Vitamin K deficiency is a correctable cause of prolonged clotting.

💡 Exam angle: three reliable threads — pancytopenia means marrow, fever on chemotherapy means antibiotics now, and the site of bleeding tells you whether platelets or factors are at fault before any result arrives.

Syllabus points

Marrow failure and the three cell lines
Why pancytopenia points to the marrow
Asking for the blood film
The symptom combination that raises suspicion
B symptoms
Reactive versus pathological lymph nodes
Lymphoma, tuberculosis and HIV together
Neutropenic sepsis
Why antibiotics precede the count
Tumour lysis syndrome
Platelet versus factor bleeding patterns
The practical bleeding history
Acquired causes of bleeding
Disseminated intravascular coagulation

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